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Structuring the treatment in stages

DBT organizes the treatment of clients with complex, multiple psychological and behavioural problems into a series of stages based upon the behaviours’ severity. In the treatment manual Linehan (1993a) first described three stages of treatment: pre-treatment, Stage 1 and Stage 2. She later added Stages 3 and 4 and described how a staged approach to treatment may apply to clients with problems other than BPD (Linehan, 1999). This staged approach clarifies for clients and therapists the order in which they will treat the clients’ problems. Each stage of treatment has a particular goal, and treatment targets within that stage directly address the achievement of the goal. Thus far, DBT describes only the pre-treatment stage and Stage 1 in detail. Chapter 15 discusses pre-treatment further.

Following pre-treatment, which addresses assessment, orientation and commitment, clients with a BPD diagnosis enter Stage 1, during which therapists assist clients to achieve behavioural stability. During Stage 1, therapists focus on behaviours that pose direct threats to safety and stability in order to increase clients’ immediate life expectancy and to decrease the frequency and intensity of their seriously destabilizing and dysfunctional behaviours. In Stage 1 of treatment. DBT therapists organize the treatment of clients’ behaviours around a structured series of targets. First in priority are life-threatening behaviours (suicidal, parasuicidal, homicidal and other imminently life-threatening behaviours), followed by therapy-interfering behaviours and quality-of-life-interfering behaviours (see Chapter 16). This book focuses on the structuring and execution of Stage 1.

The most significant change to Stage 1 since the original treatment manual (Linehan, 1993a) is the inclusion of post-traumatic stress disorder (PTSD) as a Stage 1 quality-of-life interfering behaviour. Linehan originally feared that clients in Stage 1 were too emotionally vulnerable and impulsive to tolerate evidenced-based treatments for PTSD and that consequently their suicidal behaviours would increase if PTSD were targeted. Thus, she suggested that the treatment of PTSD should occur in Stage 2 when clients had behavioural control and more emotion regulation. Harned et al. (2014), however, have subsequently adapted Foa’s exposure treatment for PTSD as an intervention for Stage 1 DBT and evaluated the adaptation in a randomized, controlled trial. This adaptation includes strategies to address Linehan’s concerns about PTSD treatments eliciting suicidal behaviour. In the trial, the adaptation reduced PTSD significantly more than the control condition, without significantly increasing suicidal behaviour.

If a client has successfully completed Stage 1, the therapist and client assess the client’s remaining problems and establish the most appropriate next stage. The therapist’s recommendation of specific interventions for a given stage will depend upon the empirical evidence and available resources for those interventions and the client’s motivation. Whether the client addresses future stages with the current DBT therapist will also depend upon the capability of that therapist to apply the appropriate interventions and the capacity of the DBT programme to extend the treatment duration.

The additional stage most often provided by comprehensive DBT programmes is Stage 2. This stage focuses on processing emotions that do not cause behavioural instability but that do cause “quiet desperation”. Problems for this stage include painful unwarranted emotional sensitivity or reactivity to situations and problematic emotional avoidance. Clients may have remaining psychological or interpersonal issues associated with a psychiatric diagnosis (e.g. sense of emptiness, uncertainty about identity) or with a history of notable loss or invalidation during childhood. Stage 2 also would apply to clients who did not develop PTSD as a result of sexual or other physical trauma but who suffer from non-psychiatric consequences, such as unwarranted shame or maladaptive self-invalidation.

DBT particularly attends to the contingencies in both the DBT programme and the wider treatment system regarding the progression from Stage 1 to Stage 2. For cases in which the client has more motivation to work on Stage 2 issues than Stage 1 targets, clarifying that

Stage 2 work will begin as soon as but not until the client has completed Stage 1 can motivate clients to collaborate more and otherwise work harder in Stage 1. In healthcare systems under resource pressure and focused primarily on the management of risk, clients may face a reduction or withdrawal of treatment resources as their risk decreases and behavioural stability increases, regardless of continued psychological distress. For clients who have Stage 2 issues, such a reduction in treatment may result in notable clinical deterioration. This deterioration occurs when clients cannot tolerate the Stage 2 issues in the longer term and when they experience the withdrawal of services as a punishment for progress and consequently become less motivated to solve problems themselves. Thus DBT programmes endeavour to ensure that clients who have completed Stage 1 successfully but need a Stage 2 treatment are either treated within the DBT programme or receive a referral to an appropriate Stage 2 programme.

The private sector most often provides interventions for Stage 3 and 4 interventions. Stage 3 aims to assist clients to solve ordinary “problems in living” and to achieve ordinary levels of happiness and unhappiness. Examples of Stage 3 problems include common types of marital conflict, issues in parenting teenage children and career challenges. Clients can obtain treatment for such problems through private clinical practices, workshops and online courses, voluntary organizations, peer support groups and various media (e.g. books, videos). Stage 4 aims to enhance the capacity for joy and focuses on assisting individuals for whom ordinary happiness and unhappiness remain insufficient and who continue to experience a degree of meaninglessness or absence of connectedness. Non-clinical options for this stage include spiritual practices and philosophical pursuits. Though publicly-funded mental health systems rarely treat Stage 3 and 4 problems themselves, discussing these stages at the beginning of Stage 1 in such settings may encourage hope early in treatment and later facilitate transition out of mental health services. In particular, a discussion of all of the options that support continued selfdevelopment may challenge the frequent maladaptive belief that only mental health systems can help.

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